Chapter 50 Nail Disorders

Question 1

What are common nail disorders that primary care providers should be familiar with?

Answer 1

• Herpetic whitlow
• Paronychial infections
• Onychomycosis
• Nail changes indicating underlying issues

Nail disorders can indicate infection, disease, malnutrition, trauma, or malignancy.

Question 2

What is the definition of herpetic whitlow?

Answer 2

A self-limited viral infection of the area between the fascial planes of the distal finger, usually surrounding the nail

Most often seen in patients with herpes simplex infections.

Question 3

What are the symptoms of herpetic whitlow?

Answer 3

• Severe redness
• Swelling
• Pain
• Stiffness in the finger
• Herpetiform vesicles or blisters

Symptoms develop 2 to 14 days after exposure and generally resolve in about 3 weeks.

Question 4

What is the pathogen responsible for herpetic whitlow?

Answer 4

Herpes simplex virus (HSV-1 or HSV-2)

Transmission may occur from a primary herpetic lesion or infected body fluids.

Question 5

True or false: Immediate referral is indicated for patients with possible tenosynovitis presenting with severe symptoms.

Answer 5

TRUE

Immediate surgical intervention may be required.

Question 6

What are the essential diagnostics for herpetic whitlow?

Answer 6

• History and physical examination
• Viral culture of vesicular fluid
• Tzanck smear
• Serum titer (if warranted)

Diagnosis is typically established based on clinical findings.

Question 7

What are the priority differentials for herpetic whitlow?

Answer 7

• Tenosynovitis
• Bacterial infection
• Candidal infection
• Felon
• Paronychia
• Warts

These conditions may present with similar symptoms.

Question 8

What is the nonpharmacologic management for herpetic whitlow?

Answer 8

• Cool compresses
• Covering the area with gauze
• Keeping the area dry

Moisture may prolong healing and promote superinfection.

Question 9

What oral antivirals may be considered for severe cases of herpetic whitlow?

Answer 9

• Acyclovir
• Famciclovir
• Valacyclovir

These may be used during the prodromal period or for management of recurrences.

Question 10

What is the definition of paronychial infections?

Answer 10

Acute or chronic inflammation of the tissues surrounding the nail, usually with an underlying bacterial or fungal infection

Noninfectious causes may include chemical irritants and excessive moisture.

Question 11

What are the risk factors for paronychial infections?

Answer 11

• Frequent manicures
• Acrylic nails
• Exposure to chemicals
• Psoriasis
• Diabetes mellitus
• Immunosuppression

Patients who frequently have their hands in water are also at risk.

Question 12

What are the clinical presentations of paronychial infections?

Answer 12

• Throbbing pain
• Distal onycholysis
• Discoloration
• Erythema and edema of the nail folds

Symptoms usually localize to one finger.

Question 13

What are the initial diagnostics for paronychial infections?

Answer 13

• Bacterial culture and sensitivities
• Potassium hydroxide preparation
• Complete blood count and differential (if infection complication is suspected)

Diagnosis is often established based on history and physical examination findings.

Question 14

What is the definition of onychomycosis?

Answer 14

An infection of the nails caused by a dermatophyte, yeast, or sometimes mold

Onychomycosis is the most common nail condition.

Question 15

What are the symptoms of onychomycosis?

Answer 15

• Nail discoloration
• Thickening
• Roughness
• Splitting of the nail
• Onycholysis

These infections are often difficult to resolve.

Question 16

What is onychomycosis commonly associated with?

Answer 16

• Nail discoloration
• Thickening
• Roughness
• Splitting of the nail
• Onycholysis

Onychomycosis is the most common nail condition and is often difficult to resolve.

Question 17

List the risk factors for onychomycosis.

Answer 17

• Advancing age
• Swimming
• Nail trauma
• Diabetes
• Tinea pedis
• Psoriasis
• Immunodeficiency

These factors contribute to the likelihood of developing onychomycosis.

Question 18

What are the common pathogens associated with tinea unguium?

Answer 18

• Trichophyton rubrum
• Trichophyton interdigitale
• Candida organisms

Molds can also be causative agents.

Question 19

What is the most common presentation of onychomycosis?

Answer 19

Distal subungual onychomycosis

It begins with discoloration in the distal portion of the nail.

Question 20

What is the rare presentation of onychomycosis that occurs mostly in immunocompromised patients?

Answer 20

Proximal subungual onychomycosis

This type begins deeper near the cuticle.

Question 21

What are the clinical presentations of distal or lateral subungual onychomycosis?

Answer 21

• White to brownish-yellow discoloration
• Subungual hyperkeratosis
• Separation of nail plate and nail bed

These manifestations are indicative of the condition.

Question 22

What diagnostic test is considered the gold standard for confirming onychomycosis?

Answer 22

Fungal culture of nail debris

This test is essential to identify the invading organism.

Question 23

What are the priority differential diagnoses for nail changes?

Answer 23

• Malignancy
• Psoriasis
• Trauma

Onychomycosis accounts for about 50% of nail abnormalities.

Question 24

What is the preferred treatment for confirmed onychomycosis?

Answer 24

• Terbinafine (Lamisil) orally
• Ciclopirox nail lacquer (if oral therapy is contraindicated)

Terbinafine is effective for toenails and fingernails.

Question 25

What should be monitored when prescribing **terbinafine**?

Answer 25

* Liver function tests (LFTs) * Creatinine clearance ## Footnote These tests should be performed at baseline and 6 weeks after starting treatment.

Question 26

What are some **patient education** points for preventing onychomycosis recurrence?

Answer 26

* Keep nails dry * Avoid tight-fitting shoes * Apply ciclopirox 2-3 times a week * Trim nails regularly ## Footnote These practices can help prevent reinfection.

Question 27

What are the **immediate referral indications** for nail changes?

Answer 27

Changes accompanied by life-threatening symptoms ## Footnote Severe redness, swelling, pain, and stiffness may indicate tenosynovitis.

Question 28

What are some **causes** of nail changes that warrant investigation?

Answer 28

* Trauma * Infection * Underlying disease * Malignancy * Nutritional deficiencies ## Footnote Nail changes can indicate serious health issues.

Question 29

What is **longitudinal melanonychia**?

Answer 29

A longitudinally oriented brown to black band extending the length of the nail plate ## Footnote This condition may indicate malignancy.

Question 30

What are some **common pediatric nail conditions**?

Answer 30

* Onychomadesis * Trachyonychia * Longitudinal melanonychia * Onychophagia * Onychocryptosis ## Footnote These conditions are important to recognize in pediatric patients.

Question 31

What are the **complications** of misdiagnosis in nail conditions?

Answer 31

* Worsening infection * Improper treatment * Delay in diagnosis of malignancy ## Footnote Misdiagnosis can lead to poor prognosis.

Question 32

What are some **tips for healthy nails** according to the American Academy of Dermatology?

Answer 32

* Keep nails clean and dry * Cut nails straight across * Avoid using nails as tools * Wear properly fitting shoes ## Footnote These practices promote nail health.